Post-traumatic Stress Disorder (PTSD) features three main symptoms: (1) re-experiencing the trauma, (2) avoidance of trauma reminders, and (3) a persistent sense of threat (Karatzias et al., 2017; Veic, 2025) and often affects military personnel (Provan et al., 2024).
The standard treatments for PTSD include medications (e.g., serotonin reuptake inhibitors; SSRIs), psychotherapy (e.g., cognitive processing therapy; CPT), and eye movement desensitisation and reprocessing, known as EMDR (Provan et al., 2024). Many veterans face barriers to accessing care (Rozek et al., 2023; Veic, 2023), and interest in equine-assisted services (EAS) for this population is increasing. EAS uses horses for therapy, learning, and horsemanship, which can alleviate mental health issues like depression or anxiety (Earles et al., 2015).
The current study (Provan et al., 2024) aimed to:
- Conduct a systematic review to assess the benefits of equine-assisted services (EAS) on PTSD symptom severity in military veterans and,
- Examine short-term outcomes, intervention quality, access barriers, and results during and after treatment.
With barriers to traditional PTSD treatments, equine-assisted services (EAS) are gaining attention as a potential therapy option for veterans, and this new study examines the existing evidence base.
Methods
Search strategy
The systematic review the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021) but was not prospectively registered. The original research was reviewed on equine-assisted therapy (EAT) for PTSD in peer-reviewed journals using PubMed, JSTOR, and Science Direct. Discrepancies were resolved through discussion among the authors, and duplicates were removed using Excel.
Types of studies
The initial search focused on randomised controlled trials (RCTs), but this was expanded to include all study designs due to the limited number of RCTs, with no restrictions on assessment timing.
Types of comparators
Comparators included: 1) no treatment; 2) pre-EAT; and 3) post-EAT treatment.
Types of outcome measures
The primary outcome was PTSD severity, assessed using the PTSD Checklist for DSM-5 (PCL-5) or PCL-Veterans/Military (PCL-V-M) (Weathers et al., 2013), both pre- and post-EAT treatment. A secondary qualitative analysis of wellbeing was included, along with assessments of meaningful changes in PTSD scores.
Inclusion criteria focused on military veterans with PTSD/moral injury treated with equine-assisted therapy. Exclusions were children, civilian populations, other mental health disorders, therapy involving other animals, and non-peer-reviewed articles.
Data extraction and synthesis
Duplicate studies were removed, followed by screening titles and abstracts for relevance, and any discrepancies were resolved through discussion. A systematic bibliography review identified additional relevant articles. Data extracted included author details, study characteristics, patient demographics, EAS programs, outcomes (PTSD scores pre- and post-EAS treatment and clinician-administered PTSD scores; CAPS-5). Other qualitative outcomes included partner involvement, peer support, barriers and outcomes to EAS programmes, and additional benefits of EAS (e.g., opportunities for reflection).
Risk of bias assessment
Risk of bias was evaluated using RoB2 for RCTs (Higgins et al., 2011), ROBINS-I for non-randomised interventional studies (Sterne et al., 2016), and ROBINS-E (Higgins et al., 2024) for one observational study. Two authors independently assessed bias and resolved discrepancies through discussion.
Statistical analysis
PTSD scores measured via PCL from more than three studies were eligible for meta-analysis using RevMan 4.0 software with a random effects model. Mean differences and 95% confidence intervals were reported. Heterogeneity was assessed using I², Chi², or Tau² statistics. Despite only two studies providing CAPS-5 scores, a meta-analysis was also conducted for these scores using the same parameters as PCL.
Results
Searches of three databases yielded 111 results: 12 from PubMed, 25 from JSTOR, and 74 from Science Direct. In total, there were 13 relevant studies to address the research question: is EAS beneficial for military veterans with PTSD?
Study characteristics showed that the included studies, published between 2016 and 2023, mostly originated from the US (11 studies), with one each from Australia and Israel. Among them, two were RCTs, 11 were clinical studies (evaluation, pilot, and open trials), and one was observational. The total participant count across studies was 344, predominantly male (76%), aged 37–58 years. EAS types included therapeutic horseback riding (THR) and psychotherapy involving horses (PIH), along with combinations of equine-assisted learning (EAL).
Risk of bias assessment indicated that while the RCTs had a low risk of bias, interventional studies showed 30% with low risk, 60% with some concerns, and 10% at high risk. Concerns were noted particularly in participant selection bias.
Type of EAS treatment revealed that eight studies used PIH, involving activities with horses alongside psychotherapy. Groundwork, grooming, and riding were common activities, with variations in psychotherapy techniques. Riding duration correlated with greater alleviation of PTSD symptoms. Some studies combined EAL with PIH, and treatment frequency varied from intensive options to weekly sessions, spanning durations of 4-8 weeks or up to 6 months.
Nine studies used the PTSD Checklist (PCL) in various forms (PCL-5, PCL-V, PCL-M), which assesses the 20 DSM-5 PTSD symptoms. Other measures included the Clinician-Administered PTSD Scale (CAPS) (Fisher et al., 2021), PACES, and PHQ-9 (Marchand et al., 2023).
Participants were diagnosed with PTSD, and the studies showed short-term improvements (up to 6 months) in symptoms but lacked long-term follow-up. Improvements in PTSD severity using the PCL ranged from 4.02% to 50.68%, with a mean percentage improvement of 22.59%. Results should be interpreted cautiously due to moderate to high risks of bias and the lack of standardized interventions.
A meta-analysis indicated a significant reduction in PTSD severity with a mean reduction of 12.46 for PCL scores and 12.62 for CAPS-5 scores, highlighting the need for caution in interpreting these findings due to the low quality of the studies.
From the qualitative analyses the authors revealed further findings. Studies involving family in EAS phases showed positive outcomes in depression, stress, and quality of life. Peer support was also noted as beneficial, providing social engagement among veterans. MRI studies suggested changes in neural systems related to PTSD after EAS. Other benefits included skill development, relationship building, and personal reflection, though these need confirming through high-quality studies.
A review of 13 studies suggests equine-assisted services (EAS) may reduce PTSD symptoms in veterans, but methodological limitations highlight the need for higher-quality research.
Conclusions
The systematic review and meta-analysis highlights various studies assessing how working with horses can aid in reducing symptoms of PTSD and improving overall well-being. The unique bond that can form between veterans and horses, along with the calming presence of these animals, is shown to provide therapeutic benefits.
By synthesising findings from multiple studies, the review offers an initial look at the potential advantages of this unconventional therapy, but firm conclusions cannot yet be drawn.
Strengths and limitations
The study by Provan et al. (2024) provides valuable insights into the potential benefits of equine-assisted services (EAS) for military veterans suffering from PTSD. The authors developed a clear and well-defined research question to assess an innovative approach to mental healthcare. Through a systematic review and meta-analysis, the researchers thoroughly examine existing research, uncovering both strengths and limitations of EAS as a treatment option.
One significant strength of the study is its comprehensive synthesis of multiple studies, which aggregates a substantial body of evidence and enhances the generalisability of the findings. This approach allows the authors to evaluate trends and outcomes across diverse populations and settings, providing a broad perspective on the effectiveness of EAS for PTSD treatment. Additionally, the incorporation of quantitative analysis allows for a more objective measurement of the effect size of EAS on PTSD symptoms. This statistical method quantifies the benefits, offering more concrete evidence of the intervention’s effectiveness.
Despite its strengths, there are limitations to consider. The review included studies with varying designs, methodologies, and participant characteristics, which complicates the interpretation of the results. This heterogeneity can lead to differing outcomes and makes it difficult to establish a universal conclusion regarding EAS. Only two of the included studies were randomised controlled trials (RCTs), and these were very small studies. Overall we need more and larger RCTs before we can be sure that equine-assisted services (EAS) are safe and effective for treating PTSD in military veterans.
Moreover, most of the included studies were conducted in the US, which has a different healthcare system to the UK and other EU countries due to privatisation. Although EAS is steadily making its appearance in the UK as a treatment option for people with severe mental illnesses, it was surprising to see no relevant studies in this review. This may highlight, that despite important work being done on this front in the UK, dissemination is not widespread or systematic, potentially limiting awareness among researchers, clinicians, and policymakers.
Furthermore, many of the studies reviewed were of moderate to low quality, with small sample sizes and limited control of confounding variables, raising concerns about the robustness and generalisability of the findings. Most studies focused on short-term outcomes, leaving the long-term effectiveness of EAS uncertain. The lack of long-term follow-up data makes it challenging to ascertain whether the benefits of EAS are sustained over time.
Finally, the reliance on published studies raises the possibility of publication bias, where positive results are more likely to be reported, potentially skewing the overall findings and overestimating the effectiveness of EAS.
Provan et al. (2024) highlight the emerging evidence of equine-assisted services for veterans with PTSD, but limitations in design and data quality emphasise the need for more rigorous investigation.
Implications for practice
This review suggests that equine-assisted services (EAS) may be a valuable complementary or alternative treatment for PTSD, but the variability in study designs and the limited long-term data indicate that more evidence is needed. The current evidence base is largely derived from small, non-randomised studies. Therefore, EAS should be regarded with caution and considered an emerging area of research rather than a treatment ready for widespread clinical use.
Integration into existing therapeutic programmes. EAS has been explored as a possible adjunct in certain therapeutic contexts, particularly where conventional/traditional treatments, such as CBT or medication, have not been effective. Since EAS focuses on non-verbal interaction with horses, it may resonate with veterans who find it difficult to engage in more conventional therapies that involve discussing traumatic events. The therapeutic bond that forms between veterans and horses might provide an avenue for emotional expression, offering benefits such as reduced anxiety and increased feelings of empowerment. Mental health professionals may wish to explore EAS in pilot or research contexts, i.e., service-related and quality improvement projects, but widespread integration is premature.
Multidisciplinary approaches. For EAS to be effective, it must be part of a holistic, multidisciplinary approach to PTSD treatment. Collaborative care models that include mental health professionals, equine specialists, and veteran support services can help ensure that EAS interventions are designed to meet veterans’ unique physical, emotional, and psychological needs. Appropriate training and certification for equine therapists would be necessary in any future clinical use of EAS to ensure that people are receiving high-quality and evidence-based care.
Accessibility. EAS programs could be geographically and financially accessible to veterans across the country, especially given the rural or isolated locations where many veterans reside.
Need for continued research and evaluation. Given the study’s identified limitations, practitioners should be cautious in fully endorsing EAS until more robust and high-quality research confirms its long-term efficacy. Future studies should aim to standardise EAS protocols, incorporate diverse veteran populations, and explore the sustainability of its benefits over time. Equine-assisted services may offer short-term benefits for veterans with PTSD, but stronger evidence is needed before they can be recommended as a routine treatment option.
Clinicians could explore equine-assisted services as a possible complementary approach for veterans with PTSD, but recommendations should await stronger evidence from high-quality trials.
Statement of interests
No conflicts of interest to declare.
Links
Primary paper
Provan, M., Ahmed, Z., Stevens, A. R., & Sardeli, A. V. (2024). Are equine-assisted services beneficial for military veterans with post-traumatic stress disorder? A systematic review and meta-analysis. BMC psychiatry, 24(1), 544.
Other references
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